Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Hi Dr. Sher,
I am 32 yo with PCOS and have been ttc my first child since 6/2016. My husband has no issues. I am not overweight, 118 lbs at 5’5. I’ve had 7 failed IUIs and moved did IVF last year and ended up with 10 good quality embryos. 5 made it to day 5, 4 5AA and one 5AB. 5 more made it to day 6, also great embryos.
My fresh transfer resulted in a CP with a 1st beta of 7.8 followed by 0. My first FET also failed. Then we did PGS testing and ERA which showed I needed an extra 24 hours of PIO. After PGS we had 6 left (3DB, 5AB, and 4 that were 5BB). We just found out our FET #2 failed. We are shocked because we were hoping the ERA would be the answer to our problems.
After the first failed transfer, I had the immunology tests for hypercoagulable states and NK cells. Nothing showed up. Other tests I’ve done include an HSG which showed no blockages. Two hysteroscopies and endo scratches that showed no issues or inflammation.
What do you think we could be missing? What other testing would you recommend? Do you think it’s possible I have silent endo?
We don’t want to do another transfer without making some changes.
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa). In my opinion, there are only a handful of reproductive immunology reference labs in the U.S.A that can do the K-562 target cell test (required for measuring NKa), reliably.
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
•The Fundamental Requirements for Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Blastocyst Embryo Transfers should be the Standard of Care in IVF
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF?
•The Role of Nutritional Supplements in Preparing for IVF
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*The 4th edition of my book,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
I am 42 y.o. We have gone through 5 IVF cycles (w Egg Retrievals). We opted for PGS testing. And in most cycles we sent at least one embryo to be tested. We got one “normal” embryo and around five “abnormal”. Considering the issue of mosaicism and the possibility of up to a 30-40% error rate, we asked our clinic to save the “abnormal” embryos.
My case also includes the discovery of immune issues impacting my pregnancy. We learned of this after the 5 IVF cycles when we decided we should consult with an immunologist due to a miscarriage I had (after an
IUI) that coincided with a significant “allergic response” (rash,etc.).
While we probably have more questions, the one weighing on us currently is the possibility of transferring the “abnormal” tested embryos (several of which were Grade 1) What is your opinion on transferring aneuploid embryos? Will your practice do these transfers in some cases? Thanks so much for your time and feedback.
Hi… doc i really need ur help…i did my ivf on 24 of july it was 3 days embryo implant.. three embryos were implanted ..I did my first test on 9 day which is 1 of aug it was 131.4 i did my sec beta hcg test on 6 August it was 168.. on 8 i again went for a test it was 59… but doc said to me he could see the sac…on the vry next day on 9 of August i again went for beta hcg n it was 203… i haven’t got my period neither i have any spotting i had pain in my pelvic area on 8 of August on 9 i again visited my doc he said that ultrasound is ok… i don’t know what is going on i m vry confused about my beta hcg… the doc said he could see one sac in last ultrasound.. can i still hope for something good… plz reply me
This does not look optimistic…I am afraid. I think the pregnancy is failing!
So sorry!
Geoff Sher
I saw your autoimmune webinar, first of all thank you! 2 questions:
1. you said TSH above 3,5 would be a concern. I’ve been tested a lot in the last years and TSH was always within the normal range. But i had 3 miscarriages after a healthy baby. The first and third at 5,5 weeks. The second at 9 weeks (discovered at 11). During this pregnancy my TSH level was 3.88. Do you think it’s normal or a reason for concern? I have been tested for hormonal levels, antibodies and blood clotting disorders and all seems fine. All my miscarriages were natural so no karyotype tests have been done. I hope my doctor will agree to test my husband and me. I’m 38 and although i lead a healthy lifestyle i have multiple hypothyroid symptoms, anemia, bad absorption, low bone density and recurrent infection (flu, sinusitis etc)
2. At which stage of the cycle should the natural killer cells activity be tested? Or only during pregnancy? Thank you so much!
If you test negative for antithyroid antibodies and for NK cell activation, I would not be concerned. The latter can be tested any time in the cycle.
Geoff Sher
Dear Dr.
I am planning to do the 3rd IVF in the end of this year. However I am worried about my chlamydia trachomatis (CT) test. In 2015 I tested CT using blood test ELISA Method in private medical laboratory and it resulted positive for both IgM and IgG. So in October 2015 me and my husband each took Azithromycin 1 g single dose and right in the next day we took Doxycycline 100 mg orally twice a day for 10 days and we refrained from sex during those time. Feared that it wont worked, the next month we again took Doxycycline 100 mg orally twice a day for 14 days and we refrained from sex during those time. After 3 months had passed i tested again in the same laboratory, using blood test ELISA Method, however both IgM and IgG still resulted positive, but my cervix swab test (I forget the name of the method) detected no CT and no other vaginal bacteria/etc .
Then in 2016 I consulted with an Obgyn in local hospital, so she did cervix swab test (I forget the name of the method), the result stated that it detected no CT but gardnerella vaginalis so the doctor prescribed me medicine to resolve it. However, to ensure that the CT has perfectly gone, she prescribed me and my husband Doxycycline 100 mg orally twice a day for 10 days and refrain from sex during those time. After 2 months, I tested again in the previous private laboratory, and my CT ELISA blood test for both IgM and IgG still comeback positive. When I consulted with the obgyn, she said that I shouldn’t be worry because the swab showed no CT and there was no abnormal vaginal discharge existed. Then in the end of 2016 I did a Laparoscopic surgery to make sure that my reproduction system is normal (including fallopian tube, endometriosis, etc) and whether i am able to have baby in normal way. The result is good, no abnormalities found. After months have passed, I tested again the CT using the the same metode, blood test ELISA, in the previous private laboratory, however my result still the same, the IgM and IgG still positive. Then in 2017 when I did my first IVF, prior to the stimulation process, to ensure that the CT had completely gone, the doctor gave me and my husband Doxycycline 100 mg orally twice a day for 10 days and refrained from sex during those time (I made it 14 days, just to make sure it worked!). The IVF failed. Then I did 2nd IVF in 2018 and it failed too. Then in May 2018 I did a CT/NG DNA real time PCR test in the same private laboratory and the result said “Undetected” for both CT and NG, but my blood test using ELISA method for the CT resulted positive for IgM and negative for IgG. Meanwhile my husband’s blood test (ELISA Methode) done in the same date resulted positive for both IgM and IgG.
Until this very day, I am curious, whether the so many treatments that me and my husband did for CT have worked or not? Whether the ELISA blood test for CT is reliable or not? Why after years my ELISA blood test for IgM still positive while the IgG turns negative (meaning I am continuously experiencing primary infection)? However my husband’s ELISA blood test for IgM and IgG both still positive (meaning for years he is continuously experiencing primary and/or recurrent infection)? Shouldn’t it be the opposite that through time the IgM becomes negative and IgG becomes positive especially after years of treatments? Should I worry with this blood test doctor? Or should i just rely on the CT PCR test and other swab tests that showed negative/undetected results? Should I move on to do the 3rd IVF? Or what should I do? I am worry because many websites stated that untreated CT may cause failed and abnormalities in pregnancy. Please advise and thank you in advance for your reply.
Your case is unusual. However, if all other tests are negative, I would notbe alarmed. You should however discuss this with an infectious disease expert. I also do not believe that this is in any way causing IVF failure. Something else is likely afoot!
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
•The Fundamental Requirements for Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Blastocyst Embryo Transfers should be the Standard of Care in IVF
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF?
•The Role of Nutritional Supplements in Preparing for IVF
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD